nose anfl naso-pharynx of all asthmatics should be carefully examined.

Physical Signs. In the intervals of the attacks the physical signs are
those of the co-existing pulmonary condition. During the paroxysm they are
these plus the t}3)ical signs of an asthmatic attack which are as f oUows : Inspec-
tion reveals rapid respiration carried on with much effort but with little move-
ment of the thorax; there is retraction of the supra- and infra-clavicular,
and intercostal spaces, as well as of the abdomen. Palpation reveals a ronchal
fremitus which may obscure that of the voice. Percussion is normal unless
there is a co-existent emphysema. Auscultation. Over both chests sonor-
ous and sibilant breathing so marked in character as, at times, to be per-
ceptible without approximating the ear to the thorax, is heard. So typical
is this breathing that, once it has been heard, no difi&culty in recognizing it
wiU be experienced. As the attack subsides moist rales become audible,
and the sibilant and sonorous sounds diminish.

Treatment consists in (a) the attempt to cut short the attack and in (b)
the prevention of subsequent paroxysms. The best means of accomplishing
the former object is for the patient to inhale the vapor of ethyl iodide. He
may carry with him a glass-stoppered vial containing a small quantity of this
agent, for use when necessary. Its great disadvantage is its vile odor which
makes it very disagreeable to the patient's associates. Ethyl iodide in 10
minim (0.66) capsules taken every four hoiirs is also very effective but causes
disagreeable eructations.

The inhalation of a few drops of amyl nitrite or of the fumes of the various
so-called asthma powders, which usually contain belladonna or stramonium
leaves and potassium nitrate, may afford relief. Asthma powders must be
used with care and their fumes inhaled only in thoroughly ventilated places.
The following formula may be found useful: I^ stramonii foliorum, potassii
nitratis aa §i (30.0); belladonnae foliorum, cannabis indicse foliorum aa Bss
(15.0). Misce. A tablespoonful (15.0) of this powder may be burned upon
a dish and the smoke inhaled. Cigarettes made from belladonna or stramo-
nium leaves soaked in a solution of saltpetre and then dried may be smoked
with good effect. Wrapping these cigarettes in paper impregnated with arsenic
may add to their potency. The fumes of paper treated with saltpetre when
inhaled wiU sometimes cut short an attack.



SPASMODIC BRONCHITIS. 627

Hypnotics such as morphine, hydrated chloral or hyoscine hydrobromate
are recommended by certain authorities but these should be employed with
greatest caution. They are usually given hypodermatically and in ordinary
dosage. Tincture of lobeHa — nx v to viii (0.33 to 0.50) every half hour until
two or three doses have been taken — chloralformamide and scopolamine
hydrobromide — gr. 2^-^ (0.0003) hypodermatically — and atropine sulphate
may be employed.

A simple and sometimes an effective means of treatment during an attack
is a hot foot bath; and in this connection it is well to mention the fact that
some patients experience much relief from simple inhalations of steam.

Heroine by some observers has been found useful during the paroxysm
and may be given hypodermatically in doses of y ^ grain (0.006) every hour
during the attack and by mouth after the severity of the paroxysm is over.
It must be remembered that this drug is a morphine derivative and must be
cautiously used. The same may be said of codeine in this connection.

Dionine (morphine ethyl chloride) given hypodermatically, gr. ^V to ^
(0.003 to 0.016) is highly recommended for use during the asthmatic attack.
It is said to be as efficacious as morphine and is preferable to that drug since
no habit is likely to be induced.

The warding off of subsequent paroxysms is to be accomphshed by:

1 . Drug Medication. This consists principally of the treatment of the
co-existent chronic bronchitis (see treatment of chronic bronchitis, p. 622)
with certain additions. Iodine, given in the form of the syrup of hydriodic
acid, 5i (4-0) in a wineglass (60.0) of water half an hour before each meal,
should always be tried.

Arsenic in the form of arsenic trioxide — ^o" (0-003) o^ ^ grain after meals —
or Fowler's solution — 2 to 8 drops (0.13 to 0.50) — may act well and the arsen-
iated mineral waters may be prescribed.

Sodium iodide — 5 to 15 grains (0.33 to i.oo) dissolved in water — atropine,
2^ of a grain (0.0003), ^^'^ ^^^ vomica in increasing doses are drugs which
may be employed in the intervals of the attacks.

2. Hydrotherapy. Douches and hot packs act well upon some patients.
The latter are given as follows: The patient is wrapped in a sheet wrung

out in as hot water as he can endure, over this is wrapped a blanket, and in
these the patient remains for one hour.

3. Hygienic and Climatic Treatment.

It is hardly necessary to suggest that tobacco and alcohol are, in most cases,
to be forbidden and that the patient should lead a quiet, regular life and one
as far as possible in accordance with hygienic principles. The diet is often
an important consideration; the digestion should be treated, if necessary.
The food should be easily digestible, nourishing, and taken regularly. The
lighter meats such as fowl, steak, chops, etc., and fish are allowable and the green



628 DISEASES OF THE RESPIRATORY SYSTEM.

vegetables with potatoes may be eaten. Highly seasoned dishes, rich pastry
and fried foods are better omitted. It is better that the heaviest meal come
in the middle of the day, the supper should be simple and the patient should
retire on an empty stomach. Tea and coffee in moderation may be taken.

When all is said, however, the physician will probably find it necessary to
study the diet of each patient separately and learn what is and what is not
well borne.

With regard to climate also, each case is likely to be found a law unto itself
and it may be necessary to do some experimentation before a suitable resort
can be found.

The only hard and fast statement that it is possible to make is that an
asthmatic patient should reside where he has the least number of paroxysms,
and it may be found necessary to change the residence with the seasons of
the year. Some do well in the high regions of Colorado, others in the warmer
climates of California or the southern states, while the White Mountains,
Lakewood, or the woods of the Adirondacks or Maine will be found to suit
still others.

When change of climate is impossible, as is often the case, the physician
will be surprised to see how much benefit may accrue from insistence that
the patient be in the fresh air as much as possible and that he sleep in a
thoroughly ventilated room no matter what the weather may be.

BRONCHIECTASIS.

Synonym. Bronchial Dilatation.

Definition. A dilatation of the bronchial tubes.

.Etiology. Bronchiectasis is usually the result of a chronic bronchitis
which has so weakened the walls of the bronchi that the strain put upon them
in the effort of coughing causes them to dilate. It is frequently found in
emphysema and may exist in children as a sequela of whooping cough or
broncho-pneumonia. A bronchiectatic cavity may be caused by the pressiue
of bronchial secretion retained behind an obstruction due to a foreign body
or pressure resulting from a new growth or aneurysm. Dilatations of the
bronchi may also result from the contraction of new growths of fibrous tissue
in the substance of the lung or of chronic pleuritic thickenings. These in
their contractions may so pull upon and distort the bronchi as to produce
dilatations or stenoses. Congenital bronchiectases have been described.

Pathology. Two forms of bronchiectatic cavities may occur — cylindrical
and sacculated, and both may exist in the same patient. Cylindrical bron-
chiectases are more often seen affecting the smaller bronchi, but they may be
observed in the larger tubes.

The saccular bronchiectasis occurs as a spherical or ovoid enlargement



BRONCHIECTASIS. 629

of a bronchial tube. These dilatations are usually surrounded by compressed
and indurated lung, the contraction of this tissue having resulted in the bron-
chiectatic cavity. Pleuritic adhesions by their contraction may also produce
bronchial dilatations, these usually being found at the pulmonary bases.
Tuberculous cavities oftentimes have their beginnings in bronchiectases.
The dilated wall of a bronchiectatic cavity is thinned and atrophied, this atro-
phy at times affecting its mucous lining, its muscular coat and even its fibrous
and cartilaginous envelope. The normal lining of ciliated epithelium becomes
converted into pavement cells. Ulcerations of the walls of the cavity which
may perforate into the surrounding pulmonary tissue may occur, and there
may be connective tissue proliferation which takes the form of projections
into the lumen of the dilatation.

Symptoms. The most prominent symptom is cough. This is frequently
most severe in the morning, continuing until the bronchiectases have gotten
rid of the accumulated sputum of the night. At first the cough may be unpro-
ductive, then suddenly, a copious expectoration taking place, it may cease
entirely until a reaccumulation of secretion has occurred, when the patient
will suffer another paroxysm. The paroxysmal cough followed by copious
expectoration is characteristic of this condition. The sputum is usually
typical. It is often raised by the mouthful and consists of a dull yellow-green,
unpleasantly sweet smelling muco-pus. In odor it is less fcetid than the
sputum of fcetid bronchitis. On standing it separates into three layers. Of
these the uppermost is of thin froth, the middle is mucoid and the lowermost
consists of purulent material with which are mixed degenerated epithelial
cells, granular matter, fatty acid and hsematoidin crystals and sometimes red
blood cells. Tubercle bacilli may be present if there is co-existent tuber-
culous infection.

A febrile movement is rarely present unless there is complicating tubercu-
losis or pyaemic infection.

The course of the disease depends upon the presence or absence of the
above-named infections and upon the patient's general condition. While the
changes in the lung are usually permanent they are by no means prejudicial
to the continuance of life. A spontaneous recovery has been known to take
place as a result of an obliteration due to connective tissue growth.

Physical Signs. Small bronchiectases may not be demonstrable during
life; larger ones when near the surface present the usual signs of a pulmonary
cavity. The percussion note is flat, tympanitic or cracked pot; the breathing
may be bronchial or amphoric; the voice bronchial or segophonous. Pectoril-
oquy may be present. If the cavity contains fluid, gurgling rales may be
audible. The vocal fremitus is often accentuated as a result of the surround-
ing pulmonary induration. Great variations in physical signs are frequent,
depending upon the presence or absence of fluid within the cavity.



630 DISEASES OF THE RESPIRATORY SYSTEM.

Treatment. Proper hygiene such as that suggested in the treatment of
emphysema and chronic bronchitis is absolutely necessary. The patient
should avoid too damp and cold climates and seek those of mild temperature.
Air too dry, and high altitudes are not likely to benefit the sufferer. The
seaside, when not too damp, is permissible. The patient must be warned
against exposure and should be advised to wear woolen underclothing the
year round.

Under proper precautions, a life in the open air in a proper climate is to be
recomdiended.

The expectoration of the accumulations of sputum may be facilitated and
the cough relieved by lowering the head of the patient. This may be accom-
plished by directing him to stoop or, if he is confined to bed, by raising the foot
of the bed ten or twelve inches.

With regard to drug treatment our primary object must be to maintain an
aseptic condition of the cavities. The inhalation of vapors of creosote (see
p. 623) and turpentine may accomplish something toward this end. Eucalyp-
tus in either of the following formulae may be employed: I^ tincturae eucalypti,
§ss (15.0); olei lavandulae, tix v (0.33). Misce et signa — 10 drops (0.66) in a
pint (500.0) of boiling water and inhale the steam. I^ eucalyptolis, r\\ Ixxv,
(5.0); spiritus lavandulae, 5v (20.0). Misce et signa — 10 to 20 drops (0.66
to 1.33) in a pint (500.0) of boiling water and inhale the steam. Inhala-
tions of one to four percent, phenol and of one-half percent, solutions of thy-
mol have been recommended.

The most satisfactory inhalation is probably that of the vapor of creo-
sote and is carried out as follows:

The patient is placed in a small room from which hangings and furniture,
except plain wooden articles, have been removed. He should be dressed in
a voluminous gown to prevent the odor of the creosote from penetrating his
clothing, his eyes should be protected by automobile goggles or an appliance
made of watch cr}'Stals and adhesive plaster and his nostrils plugged with
cotton. Creosote in a metal vessel is heated over an alcohol lamp or Bunsen
burner. The vapor of the creosote will cause the patient to cough and expec-
torate profusely. While unpleasant at first, this procediire soon becomes
tolerable and the length of the seance may be increased from a quarter of an
hour every two days to an hour or more every day. The persistent use of
this treatment is said to accomphsh excellent results.

The internal administration of medicaments calculated to render aseptic
the bronchial passages is likely to be more effective than are the attempts
to accomplish this end by inhalations. Creosote, oil of turpentine in the usual
doses or terpene hydrate, 5 grains (0.33) three times a day may be employed.
Phenol may be given in the following formula but must be stopped if any
darkening of the color of the urine is observed. I^ phenolis, gr. viiss (0.5);



PULMONARY EMPHYSEMA. 63 1

aquse destillatae, ovss (165.0); aquee menthag piperitae oiiss (lo.o). Misce
et signa one tablespoonful (15.0) every three hours.

M}Ttol is said to diminish the foetor of the expectoration. It may be given
in capsules in doses up to a drachm and a half (6.0) per day.

Eucalyptus in the form of eucalyptol — 15 to 30 drops (i.o to 2.0) per day
in capsules — or in the following formiila may be prescribed: I^ tincturae
eucalypti, n\ xlv (3.00); aquae destillatae, 5vss (22.0); syrupi aurantii, 5iiiss
(14.0). Misce et signa one tablespoonfiil (15.0) every two hoiirs.

Sodium subsulphate, one drachm (4.0) daily in divided doses either un-
mixed or in combination with eucalyptus, may be employed.

Expectorants may be used temporarily when for any reason it is suspected
that there is retention of the bronchial secretion. Of these the most satis-
factory are apomorphine, ipecac, and ammonium chloride. Ammonium
iodide may benefit certain cases.

Attempts to reach and disinfect the cavities by direct injections of antiseptic
fluids have been made but are probably useless on account of the impossi-
bility of reaching the situation of the lesion.

Hypodermatic injections of guaiacol or creosote in sterile olive oil have
been suggested. A half drachm (2.0) of a twenty-five percent, solution of
either of these substances may be given.

Chopped garlic — 4 drachms (15.0) daily in divided doses — and oil of allyl,
^ a minim (0.03) are said to favorably influence this disease, to better the
general condition and to lessen the foetor of the sputum. Both these substances
are best given in capsules.

Intratracheal injections have been strongly recommended in the treatment
of this condition but their employment, especially in tuberculous cases, is
hardly to be advised. The medicament used is generaUy some combination
such as the following: Guaiacol 2, menthol 10, olive oil 88.

The inhalation of oxygen is of little practical value.

Surgical treatment, consisting of the opening of the bronchiectatic cavity
and the evacuation of its contents, may be indicated if we are certain of the
locality of the lesion, this having been established by preliminary puncture
by an exploring needle. On the other hand the many difl&culties and dangers
of pulmonary surgery and the fact that bronchiectatic cavities are seldom
single should render us loath to recommend surgical intervention without
the most careful consideration of the aspects of the case.

DISEASES OF THE LUNGS.
PULMONARY EMPHYSEMA.

Emphysema of the lungs occurs in two principal forms: a. Interlobular
or interstitial emphysema which is the result of rupture of the walls of the



632 DISEASES OF THE RESPIRATORY SYSTEM.

air cells and an accumulation of air in the interlobular tissues. This variety
may be due to wounds of the lungs or to any violent effort during which a
considerable volume of air is suddenly introduced into the lungs, as in whooping
or other violent paroxysmal cough, muscular exertion in lifting, etc. This
variety of emphysema is difficiilt of diagnosis unless the air released from the
lungs reaches in some way the subcutaneous tissues of the neck or chest. In
such cases the existence of crepitation like that obtainable in surgical emphy-
sema renders the condition capable of demonstration.

b. Vesicular einphysema may be subdivided into (i) true vesicular emphy-
sema which is a condition characterized by an increase in the capacity of the
air vesicles followed by an atrophy of their walls, the blood-vessels of which
may be obliterated; (2) compensatory emphysema which results from the
attempt on the part of the organ or a portion of it to do the work of a diseased
portion of the same or the other lung; (3) senile or atrophic emphysema
in which a shrinkage of the chest and the lungs takes place. There is a de-
crease in the size of the air spaces and the condition is one of senile
atrophy.

From a clinical standpoint only true vesicular emphysema need be dealt
with.

.etiology. This disease is usually the result of a long standing chronic
bronchitis, which may date back even to childhood. In certain families
there seems to be a hereditary predisposition to the condition, and while it
is essentially a disease of advanced life, it is by no means unknown in young
persons and even in children.

Persons subject to asthmatic attacks, players upon wind instruments,
glass blowers and those who work in dusty or contaminated atmospheres
are prone to the disease, and singing and public-speaking are also con-
sidered predisposing causes.

The statement that emphysema and pulmonary tuberculosis do not co-exist
is without foundation.

Pathology. The costal cartilages are usually ossified and the lungs of
greater than normal volume; elevations upon the surfaces of these organs
due to dilatations of the air spaces may be visible to the naked eye. The
lungs do not as a rule collapse upon removal from the thorax. Microscopic
examination shows that the waUs of some of the air spaces are thinner than
normal, while those of others are increased in thickness; certain air spaces
will be found to communicate with others by means of openings in the pul-
monary tissue dividing them. The connective tissue framework of the lungs
is hypertrophied, and the appearance of the bronchi is that of chronic bron-
chitis (q. v.). In marked cases of emphysema there are, as a rule, co-existent
connective tissue inflammations of other organs and tissues such as the kidneys,
liver, arteries and heart muscle. There frequently is hypertrophy of the



PULMONARY EMPHYSEMA. 633

right ventricle of the heart due to the fact that the pulmonary inflammation
has rendered greater force necessary to drive the blood through the lungs.

Symptoms. The onset and progress of the disease are gradual and it may
exist for a number of years without causing noticeable symptoms. Usually
an increasing dyspnoea on exertion is the first manifestation which attracts the
patient's attention. This may vary from a mere inconvenience to a distress-
ing shortness of breath. There may be attacks of spasmodic asthma due
either to contraction of the bronchial muscxilature or of the arteries.

There is usually more or less cough with muco-purulent and sometimes
blood stained sputum. This symptom is due to the associated chronic bronchi-
tis, is more marked in the cold months and may be almost entirely absent
in summer. Cyanosis may occur as a result of diminished aeration of the
blood.

The excess of work thrown upon the right heart may result in various
cedematous conditions, and in certain cases the symptoms of the concomi-
tant kidney, cardiac or arterial lesions entirely overwhelm those of the emphy-
sema and this last escapes wholly unnoticed.

There is seldom a febrile movement; pulse rate is, as a rule, accelerated.

The disease tends to progress, but its symptoms may be greatly relieved by
proper treatment; it seldom results fatally.

Physical Signs. Inspection. The thorax is vertically lengthened giving
the tj'-pical "barrel-shaped" appearance to the chest. The respiratory
movement is slight.

Palpation. Vocal fremitus is lessened. The cardiac apex beat may be dis-
placed toward the right by the pressure of the distended lung.

Percussion. The note is usually hyper-resonant in marked cases, although
it often remains unchanged. In quality it may be either dull and wooden or
tympanitic in varying degree. Cardiac dulness is likely to be diminished in
area and the dulness due to the upper limit of the liver may be at a lower
level than normal.

Auscultation. The vesicular murmur is diminished in intensity and in
marked cases may be inaudible; expiration is prolonged and may be very
faint. Co-existent bronchitis may be evidenced by numerous rales of various
types. The pulmonic second sound is usually accentuated but may be heard
with difficulty, being overlaid by inflated lung. In cases with bronchial
asthma there is sibilant and sonorous breathing.

Treatment. The co-existing chronic bronchitis or asthma should be
treated according to the principles laid down in the sections devoted to these
subjects (see pp. 622 and 626). The drug treatment of the disease itself
may not afford marked relief and our chief dependence should be placed upon
hygienic measures.

Young persons predisposed through heredity to this morbid condition



634 DISEASES OF THE RESPIRATORY SYSTEM.

shoiild guard with utmost care against any condition, mode of life or occupa-
tion which will make for the disease. All attacks of bronchitis should receive
careful treatment and the general mode of hfe should be in accordance with
the strictest hygiene. Fresh air, proper exercise and diet are necessities
and excessive employment of the voice, the use of wind instruments and
occupations entailing the breathing of impure air are to be studiously avoided.

With regard to drug treatment we have certain conditions to meet, notably
the condition in the lung, the constant dyspnoea, the paroxysmal dyspnoea,
the arterial contraction and the venous congestion. We have no drug, unless
it be iodine, which can influence the connective tissue changes in the
lung. It may be given as potassium iodide or in the form of the syrup of
hydriodic acid and may be found to favorably influence the chronic dyspnoea
of the disease, and the attacks of arterial contraction. These last may also
be controlled by the administration of hydrated chloral or glyceryl nitrate.

The paroxysms of dyspnoea, when due to spasmodic contraction of the
bronchial musculature, are to be treated similarly to ordinary asthmatic attacks
(see p. 626). When they are the result of bronchial congestion heart stimu-
lants, caffeine sodio-benzoate gr. v (0.33) — digitalis — fluidextract, rrLi-ii (0.0O5
to 0.13) — convaUeria — fluidextract rr^ x-xx (0.66 to 1.33), may be given. This
dyspnoea may also be relieved by drugs which increase the secretion of
bronchial mucus, such as apomorphine hydrochloride gr -^ (0.002), and
dry cupping may be found useful in this connection.

Contraction of the arteries causing spasmodic dyspnoea may be treated
by arterial dilators such as glyceryl nitrate, gr. y^ to -^^ (0.0006 to 0.0012),
hydrated chloral, gr. v to x (0.33 to 0.66) or inhalations of amyl nitrite.

Most observers at present consider the exhibition of expectorants in simple
emphysema as useless.

The emphysema mixture which is found in most hospital and dispensary
formularies may be found usefiil in certain cases, combining an expectorant
with two antispasmodics and potassium iodide. The following formula is